An assessment form for pre-eclampsia care. This can be used as a user interface for a potential health open source potential project :)

1. Examination Clinic
Gestational Age: Weeks
Headache
Dizziness
Epigastric Pain
Nausea
Vomiting
Right Limb
Other Findings:
Oedema
Left Limb
Pitting Oedema
Oedema Up to Knees
Number of Miscarriages:
History of Miscarriages
Number of Abortions:
History of Abortions
Number of Partners:
History of Changing Partners
Fever
Patient is Pale
Patient is Anicteric
Patient is Dehydrated
Blood Pressure: / mmHg
Description:
Chest is NOT Clear
Maternal Ascitis
Description:
Enlarged Abdomen
Description:
Abdominal Scars
Symphysio-fundal Height:
Respiratory Rate: Cycles/min
Laboratory Findings
Fetal Heart Rate: Beats/min
Sodium:
Serum Electrolytes
Chloride:
CO2
:
Potassium:
mEq/L
mEq/L
mEq/L
mEq/L
Blood Urea Nitrogen: mmol/L
Creatinine Clearance: ml/min
White Blood Cells:
Full Blood Count
Hemoglobin:
Hematocrit:
Red Blood Cells:
cells/mcl
g/dL
%
cells/mcl
Mean Corpuscular Volume: %
Platelet Count: Platelet/mcl
Blood Clotting Profile
Activated Partial Thromboplastin: s
Prothrombin Time: s
International Normalized Ratio:
Fibrinogen:
D_Dimer:
mg/dL
ng/ml
Liver Functions
Aspartate Aminotransferase: U/L
Alanine Aminotransferase: U/L
Urinalysis
Visual Examination:
Chemical Examination:
Microscopic Examination:
Radiology Findings
Abdominopelvic Ultrasound Findings:
Medication Order
Hydralazine Aspirin
Magnesium Sulphate Nefidipine
Concentration:
Route of Administration:
Dose:
Number of times per day:
Number of Days:
mg
times
days
Signature:
Concentration:
Route of Administration:
Dose:
Number of times per day:
Number of Days:
mg
times
days
Signature:
Concentration:
Route of Administration:
Dose:
Number of times per day:
Number of Days:
mg
times
days
Signature:
Concentration:
Route of Administration:
Dose:
Number of times per day:
Number of Days:
mg
times
days
Signature:
Other Medications: